03/09/2014...03/09/2014 1 infection prevention and control a foundation course 2014 infection...

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Infection Prevention and Control

A Foundation Course 2014

Infection Prevention and

Control Multi Drug Resistant Organisms

(MDRO’s)

Patricia Coughlan,

Infection Prevention & Control Nurse

HSE South, Cork & Kerry Disability Services September 5th 2014

Overview

• Guidelines on Multi-drug resistant organisms (MDROs)

• Risk factors for Acquisition of MRDOs

• Infection Prevention and Control Measures when caring for residents carrying Multi Drug Resistant Organisms

• Case Scenarios • Management of MRSA

• Management of VRE

IP&C of MDROS in Residential Care Facilities 2014

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Are the same IP&C measures needed in all healthcare settings?


National Guidelines

www.hpsc.ie under A-Z

Guidelines on the Prevention and Control of Multi-drug resistant organisms (MDRO) in healthcare settings. 2012


National Guidelines

www.hpsc.ie under A-Z

Prevention and Control of Methicillin Resistant Staphyloccus aureus (MRSA) National Clinical Guideline 2


http://www.hpsc.ie/

http://www.hpsc.ie/

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MDRO’s – the problem

• Antimicrobials are one of the most significant discovery’s of modern medicine

• Antibiotic resistance established and growing worldwide public health problem

• Few therapeutic options available

• Cost- financial and personal

MULTIDRUG RESISTANT ORGANISMS

Microorganisms which are resistant to one or more groups of antimicrobials and include but not limited to the following

• Gram positive organisms such as

• Methicillin Resistant Staphylococcus aureus (MRSA)

• Vancomycin Resistant Enterococci(VRE)

• Gram negative organisims such as • ESBL(extended –Spectrum Beta-Lactemases) -producing E.coli and

• Carbapenem Resistant Enterobacteriaceae (CRE)


Risk Groups for Acquisition of MDRO’s

• Increasing age & underlying burden of co morbidity

• Increased contact with health services - particularly high dependency areas

•Antibiotic use

•Presence of invasive devices

•High prevalence of colonisation with MDROS has been documented in residents of LTCFs


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Preventing Antimicrobial Resistance in the Healthcare Setting

Use antimicrobials wisely-

•Treat patient/resident not laboratory result

•Treat infection not colonisation

•Treat infection not contamination

•Practice antimicrobial control

•Stop antimicrobial when appropriate

•Seek expert advice

Prevention & Control Measures in Residential Care Facilities

•Communication.

•Standard Precautions • Hand Hygiene.

• Environmental Hygiene.

•Healthcare Personnel Education.

•Use of Devices.

•Antimicrobial Stewardship.

•Additional Precautions Transmission Based Precautions.


Infection Prevention & Control Measures

• Standard Precaution must be used when caring for all resident’s/clients regardless of known or unknown status in respect of MRDO’s.

• Standard Precautions limit the transmission from potentially colonised individuals.

• Note surveillance cultures may fail to identify colonisation

• due to lack of sensitivity, • laboratory methods or • intermittent colonisation due to antimicrobial therapy.


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MULTIDRUG RESISTANT ORGANISMS

• Antimicrobial resistance is an evolving process and advice should be sought from Infection Prevention and Control Nurse in relation to the infection prevention and control management of any resident colonised or infection with a MDRO.

• Additional precautions such as Contact Precautions maybe advised for the management of some MDRO’s further advice should be sought from your Infection Prevention and Control Nurse.


Key infection control recommendations for settings outside the hospital applicable to all MDRO

• MDRO colonised patients should not be declined

admission to a long-term care facility (LTCF), day care facilities or rehabilitation services or have their admission delayed on the basis of positive MDRO colonisation status.

• Isolation of a resident with MDRO is generally not required in LTCF.

• Standard Precautions are required for the care of all patients, including patients colonised with MDRO in LTCF.

• The need to place a MDRO colonised patient in a single room or to use Contact Precautions should be determined based upon local risk assessment on a case-by-case basis.

• Routine screening for MDRO is not recommended for LTCF.

• Ref Guidelines on the Prevention and Control of Multi-drug resistant organisms (MDRO) in healthcare settings. HPSC 2012


Overview

• Infection Prevention and Control Measures for Managing MDROs

Case Scenarios

• Management of MRSA



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Case Scenario 1

• James is a 88 year old gentleman and has been living in residential care facility for the last 3 years, he attends a local day care centre 2 days a week.

• He shares a two bedded room with another gentleman.

• Previous history of MRSA in nasal and wound swabs – 1st isolated in 2005 while an in patient in an acute hospital for management of leg ulcers

• Currently James has no wounds, and is well.

• How would you manage James's care?


What is Staphylococcus aureus?

Staphylococcus aureus (S. aureus).

• gram-positive bacterium

• common cause of infection – minor skin to life threatening septicaemia

• numerous sub types of S. aureus

• nasal carriage in 30% of population at any one time, will occur in up to 80% at some

• Risk of infection increased in vulnerable groups

• Treatable with antibiotics


What is Methicilin Resistant Staphylococcus aureus?

• A strain of staphylococcus aureus which is resistant to the majority of antibiotics making it difficult to treat.

• Seen in both community and hospital settings

Majority of people are colonised with MRSA

• Colonisation is...

• the presence and multiplication of micro organisms

• without signs and symptoms of infection

• Infection is...

• the invasion of body tissues by pathogenic and opportunistic organisms

• with clinical signs of infection present

• in the right setting MRSA can cause severe infectons- bloodstream (BSI), pneumonia, skin & soft tissue (SSTI),


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Evolution of MRSA

• 1940’s, penicillin resistance emerges

• 1950’s, 95% penicillin resistance

• 1959, methicillin introduced in the UK

• 1961, methicillin resistance first reported

• 1960’s, methicillin used in labs to detect resistance

• 1970’s, MRSA outbreaks in UK & Europe

• 1979, major outbreak in Melbourne Hospital Australia

• 1981, first epidemic MRSA strain (EMRSA1)


Who is at risk of infection ?

• MRSA can cause serious infections e.g. bacteraemia, bone & joint infections, surgical wound infections

Patients most at risk of developing infection are those

• Seriously ill debilitated ,immunocompromised

• In Intensive Care Units, Oncology Units, Burns Units,

• With a variety of invasive devices i.e intra vascular catheters, catheters.

• Who have had implant surgery - joint replacements


Factors Predictive of Colonisation & Infection

Host Factors predictive of colonisation & infection amongst residents of LTCF include

• Advancing age

• Antibiotic use (independently associated with MRSA colonisation)

• Poor functional status

• Hospitalisation

• Presence of invasive devices


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Carriage of MRSA in LTCF


MRSA in LTCF

• High prevalence of MRSA carriage amongst residents of LTCFs

• Frequency of infection with MRSA in these settings appears to be low whilst colonised residents remain at the facility.

• Colonisation amongst residents of nursing homes in Belgium was associated with a higher mortality rate, but the excess mortality rate was restricted to residents with impaired cognitive function.

• The findings showed that no excess mortality was found amongst residents with normal or moderately impaired cognitive function.

• A longitudinal prevalence study in the UK found that MRSA was associated with previous and subsequent MRSA infection but was not significantly associated with subsequent hospital admission or mortality.


Staph aureus

Person who is colonised or

infected

Port of Exit Body Fluids Anterior

Nares discharge from

wounds

Mode of Transmission

Direct / Indirect Contact

Unclean hands /unclean equipment

Port of Entry Break in the skin,

Via invasive devices

Susceptible Host

Vulnerable groups , Immunocrompomised,

post procedures, invasive deivices

MRSA

CHAIN OF INFECTION

How are you going to break this

chain of infection ?

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Key Issue in providing care for James

•Adherence to Standard Precautions by all carers when providing care for James at all times!

•Adherence to Hand Hygiene for all- staff, resident & visitors.

•Individualised care for all residents.

•Managing care equipment and the environment.


What if this were in James bathroom?


Are there infection risks in James bathroom?


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Would this be safe for James?


Case Scenario 1b

• James requires elective admission to an acute hospital for hip replacement

• On prep op assessment James was screened, a nasal swab was MRSA positive.

• You are the nurse planning James care . What do you do?


Key Issues to consider to promote successful decolonisation

• Communication • With pre-op clinic • Link with IPCN where available • GP

• Is there a care plan?

• Has a decolonisation protocol & pack been provided, if not where will this be sourced?

• When will re screening be carried out?

• What swabs are needed?

• What information should be on the lab form?

• How will results be communicated?

• Who informs James of the results?


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Key Issues to consider to promote success of decolonisation

•Standard Precautions adhered to by all carers at all times!

•Consider single room for duration of decolonisation protocol NOT ISOLATION

•Change linen and clothing each day

• If a 2nd protocol is required use a 2nd decolonisation pack

•Encourage James with hygiene




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Prevention and Control of Methicillin Resistant Staphyloccus aureus (MRSA) (2013) National Clinical Guideline 2

Recommendations relevant to Non-acute healthcare given on which are detailed in the next 15 slides

1. Communication

2. Screening

3. Infection Prevention & Control Programme

4. Infection Prevention and Control Measures

5. Facilities

6. MRSA in the Home

7. Eradication of MRSA ( Decolonisation )

8. Antimicrobial Stewardship


Communication

• Good communication between healthcare facilities is essential to prevent and control MRSA.

• Healthcare facilities should be informed on admission and discharge of recent MRSA screening results, decolonisation treatments received and any requirement for post decolonisation screening. This should be included in the transfer documentation. Grade D


Screening

• Expert advice should be sought before embarking on screening for MRSA.

• Routine screening for MRSA in non-acute healthcare settings is not recommended.

• Carriage of MRSA is not a contraindication to the transfer of a patient to a non-acute healthcare setting.

• Routine screening before discharge to a non-acute healthcare facility or home is not required.


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Screening contd

• Screening before admission to an acute hospital setting may be required, especially, pre operatively for an elective procedure.

• The need for screening prior to admission should be determined by the patients’ consultant in conjunction with the hospital infection doctor, prevention and control team.

• Screening after decolonisation treatment will not normally be required after discharge. However, screening after decolonisation treatment may be requested in certain cases for example;

1. pre-operatively on the advice of the hospital admitting physician/surgeon

2. where a patient is to be readmitted to hospital for further treatment


Infection Prevention & Control Programme

Non-acute healthcare facilities should have an infection prevention and control program which incorporates 1. Monitoring for problems, including outbreaks of infection.

2. Routinely assessing all residents for their risk of acquisition or transmission of infection

3. Education of employees in infection prevention and control precautions.

4. Policy and procedure development and review.

5. Monitoring of care practices.

6. Occupational health.

7. Antibiotic stewardship.


Infection Prevention & Control Measures

• Standard Precautions are advised for the care of all residents regardless of MRSA status

• All residents should be encouraged to practice good hygiene and be assisted with this if required.

• Isolation of a resident colonised with MRSA is not generally required as this may adversely affect rehabilitation of the resident.

• The potential for transmission of infection should be considered in resident placement decisions.

• Local risk assessment of the individual and the environment will be required prior to placement, i.e. in the presence of an exudating wound which can not be covered single room placement may be appropriate.

• Contact Precautions may be required where a resident has an infection caused by MRSA or to control outbreaks of MRSA

infection.


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Facilities

• Routine facilities in all non-acute healthcare facilities

should include adequate sinks for staff hand

washing, liquid soap and paper towels in wall mounted dispensers, alcohol hand rub and hand

cream.

• In non-acute healthcare facilities, single rooms with

hand hygiene facilities should be available which can

be used for infection prevention and control

purposes.

• Newly built non-acute hospital inpatient

accommodation should comprise a minimum of 50%

single-patient rooms.


Education

• Education on standard precautions and relevant national infection prevention and control on national policies should be provided for all staff in non acute healthcare settings.

• Education on the use of invasive devices such as urinary catheters, enteral feeding tubes and tracheostomies should be provided to healthcare staff in non-acute healthcare facilities.


Decolonisation of MRSA

• MRSA decolonisation is not sufficiently effective to warrant routine use in all colonised patients.

• Excessive use of mupirocin, should be avoided as this will select for resistance.

• Decolonisation may be considered in certain cases but the likely success or impact of such therapy should be risk assessed to evaluate the aim, the required agents and whether it is likely to be successful.


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Eradication of MRSA– when should decolonisation be attempted?

Attempt at decolonisation may be considered in the following groups

1. Patients colonised with MRSA who are due to undergo an elective operative procedure especially high risk surgery e.g. cardiothoracic surgery, orthopaedic implant.

2. Patients in a clinical area where there is a high risk of colonisation leading to invasive infection, e.g. the ICU/NNU.

3. If the risk of infection is high and the consequences severe e.g. immunosuppressed patients.

4. As part of a strategy to address uncontrolled transmission despite the use of other measures.


Eradication of MRSA– when should decolonisation be attempted?

• In patients with colonisation at non-nasal sites there is a high possibility that decolonisation therapy will fail. Therefore use, in such populations, should be carefully considered and the aim and likely outcome taken into account before such therapy is initiated.

• Attempts at decolonisation are unlikely to be successful in patients with chronic skin conditions, ulcers, indwelling urinary catheters and therefore use in such populations should be carefully considered and the aim and likely outcome taken into account before such therapy is initiated.


Antimicrobial use in long term care facilities – Practical Guidance

• Antibiotic stewardship programmes should be implemented for long term care facilities.

• When antibiotics are prescribed to treat MRSA, local advice should be sought from the consultant microbiologist or infectious diseases physician.

• The use of antibiotics associated with MRSA selection or resistance should be avoided or minimised as much as possible. These include cephalosporins, macrolides and fluoroquinolones.

• Topical therapy for superficial MRSA skin infections should not be used without advice from a consultant microbiologist or an infectious diseases physician.


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Placement in Residential Care Facilities

•Placement • Consider the potential for transmission in all resident placement decisions

• Single room placement with Contact Precautions for residents with MRSA is not generally recommended

Exceptions might be

• a resident with wounds heavily colonised with MRSA, (where the wound can not be covered)

• or a resident with a tracheostomy who is unable to control their secretions


Placement in Residential Care Facilities

Residents known to be colonised with MRSA

• Can participate in group activities provided wounds are covered and good hand hygiene is adhered to.

• Can share a room with resident at low risk of acquiring MRSA

• Where facilities are available should not share with residents at increase risk of acquiring MRSA

• Residents colonised should receive care in rooms

• Single room placement for residents with wound which can not be covered


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Overview

• Infection Prevention and Control Measures for Managing MDROs

Case Scenarios

• Management of MRSA



VRE – Vancomycin Resistant Enterococci

•Enterococci – normal bacteria flora of the human and animal bowel – over 17 different species.

•Enterococci have intrinsic resistance to many antimicrobials

•Enterococci are relatively poor pathogens usually causing colonisation rather than infection


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VRE – Vancomycin Resistant Enterococci

Risk Groups

• oncology & transplant patients,

• residents with indwelling devices,

• haemodialysis patients,

• recent hospitalisation in high dependency,

• recent antibiotics vancomycin, third generation cephalosporins


Causative

Organism

Enterococci

Port of Entry

Break in the skin,

invasive devices

Susceptible

Host

Vulnerable groups ,

Immunocrompomised,

those with invasive deivices

Reservoir

Bowel of

Humans

Animal

Port of Exit Through body fluids,

secretions, excretions,

Mode of

Transmission Peron to Person

Direct or Indirect Contact Unclean hands /unclean equipment

VRE

CHAIN OF INFECTION

How are you going to

break this chain of

infection ?


Case Scenario 2

• Mary is 84 year old resident in a residential care facility. Recently treated in hospital for pneumonia requiring care in a high dependency unit. During her admission Mary was found to be carrying VRE (Vancomycin Resistant Enterococci).

• Mary has recovered and is returning to her residential care facility

• What IP&C precautions will be required when caring for Mary on her return?

• Standard or Contact ??


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VRE – Vancomycin Resistant Enterococci Infection Prevention and Control Precautions

• Standard Precautions are advised for all residents including those colonised with VRE

• Placement - assess the risk of dispersal of the microorganism into the environment

• Screening – not indicated in RCF

• Decolonisation – not applicable to VRE

• Communication- • resident should be aware of diagnosis, • on discharge the receiving health care facility/RCF

should be informed of status of the resident/patient.

• VRE is not a contraindication to admission to a RCF, access to day services or rehabilitation.

• People with VRE should be advised on and assisted to adhere to good hygiene practices i.e. hand hygiene after using the bathroom or touching any wounds or devices as a matter of routine'




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Case Scenario 2b

• Two weeks after discharge Mary develops diarrhoea.

• What actions do you take to prevent and control infection?


Consider causes of Diarrhoea?

• Infectious causes of diarrhoea include C.Difficile, Norovirus, salmonella and other bacteria & viral infection.

• In a resident known to be colonised with VRE diarrhoea will increase the risk of dispersal of the microorganism into the environment

• In a RCF all residents with diarrhoea which is suspected to be infectious should be placed in a single room on Contact Precautions

• What is diarhea?


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Contact Precautions

Refer to

• Guidelines on Infection Prevention and Control for Community & Disability Services Section 6 HSE South 2012

• Management of MDROS Appendix 5 – Summary of Contact Precautions www.hpsc.ie


Contact Precautions

• Placement -single room with en suite facilities or designate toilet or commode

• Hand Hygiene – AHR (if hands visibly clean) or antimicrobial soap-

• Soap & Water if in contact with diarrhoea

• PPE – gloves when in direct contact with the resident or their immediate environment, apron or gown depending on level of contact

• Care Equipment – dedicated or cleaned & disinfected between each person, minimise the amount of disposable supplies brought into a room

• Environmental Cleaning – increase cleaning and introduce environmental disinfection –

• With what ??


Contact Precautions

•Laundry – treat all as potential contaminated – alginate bag

•Waste – as per HCRW policy –items soiled with body fluids assessed as infectious should be disposed of as HCRW

•Duration of Precautions – until symptom free for two day and return of normal bowel pattern

•Terminal Cleaning – carried out on resolution of symptoms


http://www.hpsc.ie/

http://www.hpsc.ie/

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Placed on the outside door

Contact Precautions on the

reverse of the advice for

visitors to preserve privacy

Contact Precautions on the

reverse of the advice for

visitors to preserve privacy

Placed on the inside of the

room door for staff &

visitors leaving the room

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When a resident has diarrhoea- SIGHT

S Suspect that a case may be infective where there is no clear alternative cause for diarrheoa

I Isolate. Consult with the infection prevention and control team (IPCT) where available while determining the cause of the diarrhoea

G Gloves and aprons must be used for all contacts with the patient and their environment

H Hand washing with soap and water should be carried out after each contact with the patient and the patient’s environment

T Test the stool for C&S, C. difficile toxin, by sending a specimen immediately

Key Messages for when Managing MDROs outside of the Hospital

• MDRO colonised patients should not be declined admission to a long-term care facility (LTCF), day care facilities or rehabilitation services or have their admission delayed on the basis of positive MDRO colonisation status.

• Isolation of a resident with MDRO is generally not required in LTCF. Standard Precautions are required for the care of all patients, including patients colonised with MDRO in LTCF.

• The need to place a MDRO colonised patient in a single room or to use Contact Precautions should be determined based upon local risk assessment on a case-by-case basis.

• Routine screening for MDRO is not recommended for LTCF.

• Ref Guidelines on the Prevention and Control of Multi-drug resistant organisms (MDRO) in healthcare settings. HPSC 2012


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Standard or Contact Precautions for MRDOs ?

• The decision to isolate a resident must be considered carefully and should take into account

• the infection

• the risks to other residents,

• the presence of risk factors that increase the likelihood of transmission, and

• the psychological effects of isolation on the colonised or infected resident.

• Before isolating a resident, a plan to review the need for ongoing Contact Precautions must be in place.


Standard or Contact Precautions for MDROS ?

• Standard Precautions advised for relatively healthy independent residents colonised with an MDRO

• Contact Precautions are recommended in certain situations including .

• Ill dependent residents OR

• Residents with uncontrolled secretions/excretions OR

• Residents suffering from an infection caused by an MDRO:

• Single room accommodation is preferable, if available.


Standard or Contact Precautions for MDROS

• Cohorting of patients known to be colonised or infected with the same MDRO is acceptable.

• If cohorting is not possible, then those residents colonised/infected with an MDRO should be placed in a room

• with a resident considered to be at low risk for acquisition of an MDRO (i.e. not immunocompromised, not on antimicrobials, without open wounds, drains or urinary catheters) or

• those who have an anticipated short duration of stay.


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Other aspects of control of MDRO in LTCFs include: • Maintaining a list of residents infected/colonised with an MDRO

• Monitoring microbiology culture results of specimens sent to the local microbiology laboratory

• Communication of information relating to the status of an MDRO colonised resident to other receiving or transmitting facilities where indicated, such as upon referral to hospital or other healthcare facilities

• Ensuring adequate environmental cleaning


Wise Words

“Penicillin should only be used

if there is a properly diagnosed reason and,

if it needs to be used,

use the highest possible dose for the shortest time

necessary.

Otherwise antibiotic resistance will develop”

Alexander Fleming, 1945


3 Key Messages for Control of MRDOs in Residential Care

1. Standard Precautions for ALL- the major focus for health care workers is the reduction of contamination on hands and any equipment taken from one client to another

2. Careful use of a precious resource - Antimicrobials

3. Reduce risk of infection- vaccinate, care of devices, monitor and treat infection appropriately.

The need for additional infection control precautions in a residential setting must be

balanced with the need for a healthy lifestyle.

http://www.thefamouspeople.com/profiles/images/alexander-fleming-1.jpg

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What you can do as an individual !



References

• Guidelines on the Prevention and Control of Multi-drug resistant organisms (MDRO) in healthcare settings. 2012

• http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,12922,en.pdf

• Prevention and Control of Methicillin Resistant Staphylococus aureus (MRSA) National Clinical Guideline 2

• http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,13950,en.pdf


http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,12922,en.pdf










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Thank You !

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